Monitoring and measuring office processes and outcomes is a critical part of quality improvement work. Overall outcomes, such as improved vaccine coverage rates, are important to measure, but process measures, such as the rate of missed opportunities to vaccinate, can provide much needed information on whether interventions are being implemented consistently and reliably.

The measures set that was developed in the Improving Childhood Immunizations Project is included in Appendix B for reference, adaptation and use in your practice.

ICHIP Measures Grid

(On a smaller device, please scroll horizontally to view full table.)

Ref #

Measures Name

Measures Definition

Measure Calculation (Numerator/Denominator)

Measure Benchmark

Measure Target/Goal (%)

Collection Frequency

1

Combination 3 Vaccine Measure

The percentage of patients 19-35 months old who are up-to-date on four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B (Hib); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV)

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on:
∙ four diphtheria, tetanus and aceullur pertussis (DTaP);
∙ three polio (IPV);
∙ one measles, mumps and rubella (MMR);
∙ three H influenza type B (HepB);
∙ one chicken pox (VZV);
∙ four pneumococcal conjugate (PCV)
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

80%

Monthly

2

DTaP Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on four diphtheria, tetanus and acellular pertussis (DTaP) vaccines

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on four diphtheria, tetanus and acellular pertussis (DTaP) vaccines
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

3

IPV Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on three polio (IPV) vaccines

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on three polio (IPV) vaccines
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

4

MMR Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on one measles, mumps and rubella (MMR) vaccine

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on one measles, mumps and rubella (MMR) vaccine
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

5

Hib Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on three H influenza type B (Hib) vaccines

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on three H influenza type B (Hib) vaccines
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

6

HepB Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on three hepatitis B (HepB) vaccines

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on three hepatitis B (HepB) vaccines
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

7

VZV Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on one chicken pox (VZV) vaccines

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on one chicken pox (VZV) vaccines
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

8

PCV Vaccination Rate

The percentage of patients 19-35 months old who are up-to-date on four pneumococcal conjugate (PCV) vaccines

Target Population: All patients 19-35 months old in reporting month
Numerator: All patients 19-35 months old who are up-to-date on four pneumococcal conjugate (PCV) vaccines
Denominator: All patients 19-35 months old

Baseline rates and state/regional rates

90%

Monthly

9

Missed Opportunity Rate

The percentage of patients 19-35 months old who do not receive all eligible vaccinations when they present in the office

Target Population: All patients 19-35 months old due for a childhood vaccine and without doucmented true contraindications who were in the office during the reporting month
Numerator: All patients 19-35 months old that did not receive all eligible vaccines when they presented in the office
Denominator: All patients 19-35 months old that were due to receive a childhood vaccine (DTap, IPV, MMR, Hib, HepB, VZV, or PCV) when they presented in the office and without documented true contraindications

Baseline rates

Set by practice

Monthly